Compliance (medicine)
Encyclopedia
In medicine, compliance describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance, but may also mean use of medical appliances such as compression stockings, chronic wound
care, self-directed physiotherapy exercises, or attending counseling or other courses of therapy. Both the patient and the health-care provider affect compliance, and a positive physician-patient relationship is the most important factor in improving compliance, although the high cost of prescription medication also plays a major role.
Non-compliance is a major obstacle to the effective delivery of health care. Estimates from the World Health Organization
(2003) indicate that only about 50% of patients with chronic diseases living in developed countries
follow treatment recommendations. In particular, low rates of adherence to therapies for asthma
, diabetes, and hypertension
are thought to contribute substantially to the human and economic burden of those conditions. Compliance rates may be overestimated in the medical literature, as compliance is often high in the setting of a formal clinical trial
but drops off in a "real-world" setting.
Major barriers to compliance are thought to include the complexity of modern medication regimens, poor "health literacy" and lack of comprehension of treatment benefits, the occurrence of undiscussed side effects, the cost of prescription medicine, and poor communication or lack of trust between the patient and his or her health-care provider. Efforts to improve compliance have been aimed at simplifying medication packaging, providing effective medication reminders, improving patient education, and limiting the number of medications prescribed simultaneously.
, The American Pharmacists Association
, and the U.S. National Institutes of Health
Adherence Research Network.
Concordance also refers to a current UK
NHS
initiative to involve the patient in the treatment process to improve compliance. In this context, the patient is informed about their condition and treatment options. They are involved with the treatment team in the decision as to which course of action to take, and partially responsible for monitoring and reporting back to the team. Compliance with treatment is improved by:
study estimates that only 50% of patients suffering from chronic diseases in developed countries follow treatment recommendations. This may affect patient health, and affect the wider society when it causes complications from chronic diseases, formation of resistant infections, or untreated psychiatric illness. Compliance rates during closely monitored studies are usually far higher than in later real-world situations. For example, one study reported a 97% compliance rate at the beginning of treatment with statin
s, but only about 50% of patients were still compliant after six months.
A wide variety of packaging approaches have been proposed to help patients complete prescribed treatments. These approaches include formats that increase the ease of remembering the dosage regimen as well as different labels for increasing patient understanding of directions. For example, medications are sometimes packed with reminder systems for the day and/or time of the week to take the medicine. With the objective to support patient adherence to medicinal therapy, a not-for-profit organization (Healthcare Compliance Packaging Council of Europe/HCPC-Europe) http://www.hcpc-europe.org/cms/front_content.php?idcat=94 was set up between the pharmaceutical industry, the packaging industry and representatives of European patients organizations. The mission of HCPC-Europe is to assist and to educate the healthcare sector in the improvement of patient compliance through the use of packaging solutions. A variety of packaging solutions have been developed by this collaboration to aid in patient compliance.
The failure to complete treatment regimens as prescribed has significant negative health impacts worldwide. Examples of the rate and consequences of non-compliance for selected medical disorders is as follows:
Chronic wound
A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic....
care, self-directed physiotherapy exercises, or attending counseling or other courses of therapy. Both the patient and the health-care provider affect compliance, and a positive physician-patient relationship is the most important factor in improving compliance, although the high cost of prescription medication also plays a major role.
Non-compliance is a major obstacle to the effective delivery of health care. Estimates from the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
(2003) indicate that only about 50% of patients with chronic diseases living in developed countries
Developed country
A developed country is a country that has a high level of development according to some criteria. Which criteria, and which countries are classified as being developed, is a contentious issue...
follow treatment recommendations. In particular, low rates of adherence to therapies for asthma
Asthma
Asthma is the common chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchospasm. Symptoms include wheezing, coughing, chest tightness, and shortness of breath...
, diabetes, and hypertension
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
are thought to contribute substantially to the human and economic burden of those conditions. Compliance rates may be overestimated in the medical literature, as compliance is often high in the setting of a formal clinical trial
Clinical trial
Clinical trials are a set of procedures in medical research and drug development that are conducted to allow safety and efficacy data to be collected for health interventions...
but drops off in a "real-world" setting.
Major barriers to compliance are thought to include the complexity of modern medication regimens, poor "health literacy" and lack of comprehension of treatment benefits, the occurrence of undiscussed side effects, the cost of prescription medicine, and poor communication or lack of trust between the patient and his or her health-care provider. Efforts to improve compliance have been aimed at simplifying medication packaging, providing effective medication reminders, improving patient education, and limiting the number of medications prescribed simultaneously.
Terminology
An estimated half of those for whom treatment regimens are prescribed do not follow them as directed. Until recently, this was termed "non-compliance", which was sometimes regarded as meaning that not following the directions for treatment was due to irrational behavior or willful ignoring of instructions. Today, health care professionals more commonly use the terms "adherence" to or "concordance" with a regimen rather than "compliance", because these terms are thought to more accurately reflect the diverse reasons for patients not following treatment directions in part or in full. However, the preferred terminology remains a matter of debate. In some cases, concordance is used to refer specifically to patient adherence to a treatment regimen that is designed collaboratively by the patient and physician, to differentiate it from adherence to a physician only prescribed treatment regimen. Despite the ongoing debate, adherence is the preferred term for the World Health OrganizationWorld Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
, The American Pharmacists Association
American Pharmacists Association
The American Pharmacists Association , founded in 1852, is the first-established professional society of pharmacists within the United States....
, and the U.S. National Institutes of Health
National Institutes of Health
The National Institutes of Health are an agency of the United States Department of Health and Human Services and are the primary agency of the United States government responsible for biomedical and health-related research. Its science and engineering counterpart is the National Science Foundation...
Adherence Research Network.
Concordance also refers to a current UK
United Kingdom
The United Kingdom of Great Britain and Northern IrelandIn the United Kingdom and Dependencies, other languages have been officially recognised as legitimate autochthonous languages under the European Charter for Regional or Minority Languages...
NHS
National Health Service
The National Health Service is the shared name of three of the four publicly funded healthcare systems in the United Kingdom. They provide a comprehensive range of health services, the vast majority of which are free at the point of use to residents of the United Kingdom...
initiative to involve the patient in the treatment process to improve compliance. In this context, the patient is informed about their condition and treatment options. They are involved with the treatment team in the decision as to which course of action to take, and partially responsible for monitoring and reporting back to the team. Compliance with treatment is improved by:
- Only recommending treatments that are effective in circumstances when they are required
- Selecting treatments with lower levels of side effect or fewer concerns for long-term use
- Prescribing the minimum number of different medications, e.g., prescribing a single antibiotic that addresses two concurrent infections (though risking contributing to antibiotic resistant speciesAntibiotic resistanceAntibiotic resistance is a type of drug resistance where a microorganism is able to survive exposure to an antibiotic. While a spontaneous or induced genetic mutation in bacteria may confer resistance to antimicrobial drugs, genes that confer resistance can be transferred between bacteria in a...
development) - Simplifying dosage regimen by selecting a different drug or using a sustained releaseSustained releaseTime release technology, also known as sustained-release , sustained-action , extended-release , time-release or timed-release, controlled-release , modified release , or continuous-release , is a mechanism used in pill tablets or capsules to...
preparation that needs fewer doses during the day - Discussing possible side effects, and whether it is important to continue medication regardless of those effects
- Advice on minimising or coping with side effects, e.g., whether to take a particular drug on an empty stomach or with food
- Developing trust so patients don't fear embarrassment or anger if unable to take a particular drug, allowing the doctor to try a better tolerated alternative
Societal impact
A WHOWho
Who may refer to:* Who , an English-language pronoun* who , a Unix command* Who?, one of the Five Ws in journalism- Art and entertainment :* Who? , a 1958 novel by Algis Budrys...
study estimates that only 50% of patients suffering from chronic diseases in developed countries follow treatment recommendations. This may affect patient health, and affect the wider society when it causes complications from chronic diseases, formation of resistant infections, or untreated psychiatric illness. Compliance rates during closely monitored studies are usually far higher than in later real-world situations. For example, one study reported a 97% compliance rate at the beginning of treatment with statin
Statin
Statins are a class of drugs used to lower cholesterol levels by inhibiting the enzyme HMG-CoA reductase, which plays a central role in the production of cholesterol in the liver. Increased cholesterol levels have been associated with cardiovascular diseases, and statins are therefore used in the...
s, but only about 50% of patients were still compliant after six months.
Prescription fill rates
While a health care provider visit with a patient may result in the patient leaving with a prescription for medication, not all patients will fill the prescription at a pharmacy. In the U.S., 20-30% of prescriptions are never filled at the pharmacy. There are many reasons patients do not fill prescriptions including the cost of the medication, doubting the need for medication, or preference for self-care measures other than medication. Cost may be a barrier to prescription drug adherence, but convenience, side effects and lack of demonstrated benefit are also significant factors to a complex situation. A US nationwide survey of 1,010 adults in 2001 found that 22% chose not to fill prescriptions because of the price, which is similar to the 20-30% overall rate of unfilled prescriptions. However, analysis by health insurers suggest that patient co-payment requirements can be reduced to $0 with little or no improvement in long-term adherence rates.Course completion
Once started, patients seldom follow treatment regimens as directed, and seldom complete the course of treatment. Cost and poor understanding of the directions for the treatment (referred to as 'health literacy') are major barriers to completing treatments. As mentioned previously, the World Health Organization (WHO) has estimates that only 50% of people complete long-term therapy for chronic illnesses as they were prescribed, which puts patient health at risk.A wide variety of packaging approaches have been proposed to help patients complete prescribed treatments. These approaches include formats that increase the ease of remembering the dosage regimen as well as different labels for increasing patient understanding of directions. For example, medications are sometimes packed with reminder systems for the day and/or time of the week to take the medicine. With the objective to support patient adherence to medicinal therapy, a not-for-profit organization (Healthcare Compliance Packaging Council of Europe/HCPC-Europe) http://www.hcpc-europe.org/cms/front_content.php?idcat=94 was set up between the pharmaceutical industry, the packaging industry and representatives of European patients organizations. The mission of HCPC-Europe is to assist and to educate the healthcare sector in the improvement of patient compliance through the use of packaging solutions. A variety of packaging solutions have been developed by this collaboration to aid in patient compliance.
The failure to complete treatment regimens as prescribed has significant negative health impacts worldwide. Examples of the rate and consequences of non-compliance for selected medical disorders is as follows:
- Diabetes non-compliance (98% in US) is the principal cause of complications related to diabetes including nerve damage and kidney failure
- Hypertension non-compliance (93% in US, 70% in UK) is the main cause of uncontrolled hypertension-associated heart attack and stroke
- Asthma non-compliance (28-70% worldwide) increase the risk of severe asthma attacks requiring hospitalization
External links
- Adherence to Long-Term Therapies, a report from the World Health OrganizationWorld Health OrganizationThe World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...